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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1097124-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) was distracted by his/her headphones and cellphone which allowed a vulnerable adult (VA) to leave the facility without the SP’s knowledge or supervision. About eight minutes later, community people called 9-1-1 after discovering the VA beside a road with cold weather-related symptoms. Date of Incident(s): February 22, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 13, 2026; from documentation at the facility and law enforcement- and medical-records; and through six interviews conducted with the VA’s guardian (G) who was also the VA’s family member, the VA’s housemate (H), facility staff persons (the SP and P1), and supervisory staff persons (P2 and P3). The VA was not interviewed due to his/her limited communication skills. The VA’s support plans, including Coordinated Services and Support Plan Addendum, provided the following information: · The VA enjoyed spending time with his/her family, playing on his/her iPad, and listening to music. · The VA lived at the facility to receive services and support relating to his/her diagnoses, which included autism spectrum disorder and intellectual disabilities. The facility provided at least one staff person 24 hours a day to help with the VA’s activities of daily living, medications, meals, and money management. · The VA was susceptible to abuse from others and was unable to identify potentially dangerous situations or respond appropriately. Staff were to always know the VA’s whereabouts when in the facility and intervene in potentially dangerous situations as needed. · The VA needed “constant attention” from staff and might exhibit “negative” behaviors to get attention, including running out the facility’s door. Staff were to always have “eyes on” the VA when in the community. If the VA ran out the door, staff were to follow and redirect him/her back inside. If the VA left without supervision, staff were to look for the VA and if s/he was not found within five minutes, staff were to call 9-1-1 and a supervisory staff person. If the VA were alone in the community, s/he would not be able to identify him/herself or seek help from others. The VA was not aware of traffic or community dangers and might respond aggressively towards others. · In addition, the VA might dress inappropriately for the weather. Staff were to offer appropriate clothing choices based on the weather and activity plans. · It was typical for the VA to “continuously” pace around the facility. The G said that the VA spoke “very little, not much” and might not understand what was going on around him/her. The VA had a history of being “very quick” and running away from staff. The facility had door alarms to alert staff if a door was opened. Staff were to keep the VA occupied and keep his/her routine consistent. The facility was a single-family house where the VA lived with the H and two other housemates. The VA’s bedroom and a laundry room were on the main floor, which also had an open-concept kitchen, dining, and living room. The facility’s front exterior door was down a short hallway from the dining room area in the opposite direction of the VA’s bedroom and the laundry room. At the time of the site visit, the DHS investigator recorded that when the front door was opened, there was a high-pitched noise (alarm) that was audible from the far side of the living room and that stopped when the door was closed. Outside the facility, there were other residences, streets with speed limits up to 40 miles per hour (mph), woods, and at least one large industrial plant. A law enforcement report provided the following information: · On February 22, 2026, at 12:17 p.m., an unidentified community person called 9-1-1 requesting a “welfare check” on a roadway in front of the industrial plant or approximately 0.43 miles from the facility. Upon arriving, law enforcement officers (LEO) saw two unidentified community people trying to cover a third person, who the LEO recognized as the VA, with a jacket. The VA was barefoot and wearing sweatpants and a t-shirt. The temperature outside was zero degrees Fahrenheit (˚F) with winds approximately 15-17 mph. The LEO saw the VA’s hands and feet were “reddish pink” and his/her feet were developing “white spots.” The LEO called an ambulance to transport the VA to an emergency room. · Next, the LEO drove to the facility where P1 told him/her that the VA was missing and that the SP was outside searching for him/her. At this point, no one from the facility had called 9-1-1 to report the VA as missing. The LEO stated that given the weather conditions and the VA’s clothing at the time, “It seemed to be a gross error in judgment to try to find [the VA] first before calling 9-1-1.” · The LEO met with the H, who told him/her that the SP had been reading in the living room and that when the VA opened the front door to leave, the door alarm made a sound, which the H heard but the SP did not seem to hear. · The SP told the LEO that s/he was “distracted” by another housemate and did not see the VA leave. The SP stated, “[The VA] wonders off frequently and [s/he] has to be watched constantly.” The VA’s medical records provided the following information: · On February 22, 2026, at 1:20 p.m., the VA arrived at the emergency room via ambulance. At that time, the VA’s core body temperature was 96.4 ˚F; the VA’s skin was “cool to the touch;” and the VA’s hands and feet were “red.” The VA was diagnosed with chilblains and discharged back to the facility with instructions to take as needed Tylenol (over the counter pain medication). [Note: According to mayoclinc.org, chilblains are painful, itchy, red or purple skin lesions caused by an abnormal reaction to cold, damp conditions.] · On February 26, 2026, staff brought the VA to a follow-up appointment. At that time, the VA had chapped and dry lips; a small blister on his/her toe with some blood and clear fluid present; and mild erythema (redness) on his/her ankles. The doctor prescribed hydrocortisone cream 2.5% (prescription only – topical steroid used to treat skin inflammation) for the VA’s ankles and instructed staff to keep the VA’s blister covered with a petroleum jelly-based cream, and to use lip moisturizer and a petroleum jelly-based cream regularly for the VA’s runny nose and chapped lips. The facility’s cameras recorded movement but not audio and showed the following for February 22, 2026: · The camera showed the kitchen, dining, and living room; the VA’s bedroom door; and the entrance to the short hallway leading to the front door, which was not on camera. At 12 p.m., the VA was pacing back and forth between his/her bedroom and the living room. The SP was sitting in a living room recliner next to the H, who was asleep. The SP was holding a cellphone in his/her lap and watching a video. · At 12:09 p.m., the VA turned into the hallway leading to the front door out of camera view. The H almost immediately stirred and woke up but remained sitting and did not appear to say anything. The SP did not move. · At 12:12 p.m., the SP stood and walked to the VA’s bedroom, looked inside the room, and then returned to his/her recliner. The SP was wearing headphones with one side entirely covering his/her left ear and the other side sitting behind (not covering) his/her right ear. · At 12:26 p.m., P1 walked around the corner and began looking in rooms before running to the front door. The SP walked over to P1 and then to the front door out of camera view. · At 12:36 p.m., the LEO arrived and spoke with P1 and the H. The H said that on the day of the incident, s/he was asleep but woke up when s/he heard the front door alarm. The SP was sitting next to the H “using [the SP’s] cellphone” and did not appear to hear the door alarm. P1-P3 provided the following information: · P2 said that on January 11, 2026, s/he saw the SP wearing headphones while working. At that time, P2 told the SP that s/he should not wear headphones because s/he could not hear the clients, and the SP told P2, “I understand.” P2 was not aware of the SP wearing headphones again until s/he saw the SP wearing headphones on the camera footage during the incident. P2 said that the door alarm was loud and could be heard in the living room. P2 believed that if the SP was not wearing headphones, s/he would have heard the door alarm. · P1 said that on January 22, 2026, shortly before the incident, s/he told the SP that s/he was going into the laundry room. The SP was sitting in the living room at that time with the H and another housemate, and the VA was pacing around the living room. P1 said that typically when one staff person was in the laundry room or focused on something else, the other staff person was then aware that they were responsible for the clients. The laundry room was loud and P1 could not hear anything going on when s/he was in there. At one point, P1 came out of the laundry room and did not see the VA and immediately started searching for him/her. At that time, the SP was sitting in the living room wearing headphones. P1 said that the SP should not wear headphones at work but P1 did not believe s/he had the authority to say something to the SP about it. P1 called 9-1-1 and the SP went outside searching for the VA. The VA had a history of staying near the facility, within the facility’s yard, and so P1 expected the same for this incident. · P3 said that although there was no audio on the camera footage, it appeared the H was woken up by the sound of the door alarm when the VA opened the door and left. The H “sits up fast in the video and kind of rubs [his/her] eyes,” which was at the “exact time” when the interior lighting changed indicating the door was opened and sunlight entered the room. The SP was wearing headphones and did not acknowledge the door alarm or look up from his/her cellphone. · P1-P3 each said that the VA had a history of leaving without staff supervision. Staff were always supposed to know the VA’s whereabouts. The SP provided the following information: · On February 22, 2026, the SP was in the living room and had his/her headphones covering one of his/her ears, but s/he could still hear what was going on through his/her uncovered ear. The SP said that an unidentified supervisor had previously told him/her that s/he could wear headphones if s/he kept one ear uncovered and paid attention to what was going on. · The VA was pacing back and forth, which was typical behavior. P1 told the SP that s/he was doing laundry. The SP said that when one staff was focused on laundry, the other staff kept an eye on the VA. However, the SP also believed that at that time, P1 “was around” and helping “distract” the VA with the VA’s television. · The SP said that more than once that day, P1 went outside to his/her car and caused the front door alarm to sound and so at one point, when the SP heard the alarm, s/he believed it was P1 again. However, the SP also did not immediately see the VA and so the SP walked to the VA’s bedroom and saw feet “hanging off the bed” and believed the VA was sleeping. The SP did not enter the VA’s bedroom or check that s/he was in bed because the SP did not want to wake the VA. The SP then walked back to his/her recliner and sat down. An unknown amount of time later, P1 entered the room and asked about the VA’s whereabouts, which prompted the SP to discover the VA was not in his/her bedroom and had likely left the facility. The SP said s/he did not see the VA leave. · It was “very, very common” for the VA to be “impulsive” and leave the facility. Staff always needed to watch the VA or sit by the front door to prevent him/her from leaving. However, historically, the VA only left in the warm summer months. In the winter, if the door was opened and the VA felt the cold air, s/he would almost immediately return inside. “It was unexpected” that the VA would leave on February 22. Facility documentation stated that the SP and P1-P3 received training on the VA’s support plans, including Coordinated Services and Support Plan Addendum, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes, section 245D.07, subdivision 1 states that the license holder must provide services assigned in the person’s support plan. Conclusion: A. Maltreatment: The SP, P1-P3, the facility’s camera footage, and law enforcement- and medical-records provided information that on February 22, 2026, the VA left the facility barefoot, in zero ˚F weather, without staff supervision. Based on video times and the 9-1-1 call it was determined that the VA was outside for about eight minutes and sustained cold weather-related symptoms before being discovered by unknown community people. Staff were supposed to always know the VA’s whereabouts, have “eyes on” supervision in the community, and call 9-1-1 within five minutes if staff could not locate the VA in the community; however, this did not occur on February 22, 2026, which was inconsistent with the VA’s support plan and a violation of Minnesota Statutes, section 245D.07, subdivision 1. Regarding the delay in calling 9-1-1: Although P1 state that when s/he noticed the VA missing s/he called 9-1-1 while the SP went to look for the VA, the LEO report stated that the LEO drove to the facility where P1 told him/her that the VA was missing and that the SP was outside searching for him/her and at this point, no one from the facility had called 9-1-1 to report the VA as missing. This was after the VA was discovered in the community and on his/her way to an emergency room. The VA sustained injuries that did not require hospitalization, and it was unknown whether calling 9-1-1 sooner would have changed the outcome for the VA. Therefore, although the conduct of not following the VA’s support plan and not calling 9-1-1 within five minutes of the VA missing was inconsistent with standards of a professional care in a facility licensed by the Department of Human Services, there was not a preponderance of the evidence whether not calling or a delay in calling 9-1-1 was a failure to supply the VA with care or services, which were reasonable and necessary for the VA’s physical or mental health or safety. Regarding supervision of the VA: On February 26, 2026, while P1 did laundry the SP was sitting in the living room wearing one or both of his/her headphones and the VA left the facility without the knowledge of supervision of either. P1 was engaged in work related activities at the time, however, as the SP sat on the couch s/he was engaged with the use of his/her cell phone which was not accidental or therapeutic conduct. Given this and that the VA’s plans stated that staff were to always know the VA’s whereabouts when in the facility and intervene in potentially dangerous situations as needed and that the VA was unable to identify potentially dangerous situations or respond appropriately; that the VA had a history of leaving the facility without staff supervision; that the VA left the facility and was gone for at least sixteen minutes prior to P1 and the SP discovering the VA was missing; and that the VA was out in zero ˚F without appropriate clothing causing chilblains and blisters, there was a preponderance of the evidence that there was a failure to supply the VA with care or services, including supervision, which was reasonable and necessary for the VA’s health or safety. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. P1 and the SP were trained on the VA’s support plans, including Coordinated Services and Support Plan Addendum, and the Reporting of Maltreatment of Vulnerable Adults Act. Although P1 and the SP were each working at the time of the incident, each provided consistent information that at the time the VA left, P1 was doing laundry leaving the SP responsible for the supervision of the VA. The SP said that an unidentified supervisor had previously told him/her that s/he could wear headphones if s/he kept one ear uncovered and paid attention to what was going on. However, P2 stated that on February 11, 2026, less than two weeks prior to the incident, P2 told the SP to stop wearing headphones because s/he could not hear the clients and the SP told P2, “I understand.” On February 26, 2026, the SP chose to again wear one or both of his/her headphones, and the VA left the facility without the SP’s intervention. The video showed that at 12:09 p.m. the VA turned into the hallway leading to the front door and the H almost immediately stirred, likely indicating the door alarm sounded. The SP remained sitting until three minutes later when s/he walked to the VA’s bedroom door. The SP then returned to the recliner and at no point went to the hallway leading to the front door until 12:26 p.m. when P1 walked around the corner. This was likely approximately 16 minutes after the VA left the facility. Given the aforementioned, the SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was not “recurring” but was “serious” maltreatment. The SP was responsible for a single incident of maltreatment, which required the care of a physician due to prescription for hydrocortisone cream 2.5%. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility provided additional training for staff on supervision and elopement procedures. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Given that the facility took immediate correction action, a Correction Order was not issued for the violation outlined in this report.
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